Slide 1Center for Interprofessional Education University of
Maryland, Baltimore
October 1, 2019
Katherine Fornili, DNP, MPH, RN, CARN, FIAAN Assistant Professor,
University of Maryland School of Nursing
Negative provider attitudes inhibit one’s ability to provide
adequate services to patients with SUDs (Goplerud, Hagle,
McPherson, 2017)
Stigma and mistrust of parents by healthcare professionals:
Increase parents’ feelings of shame and incompetence; Are
counter-productive in the parents’ recovery
process; and Impact adequate bonding between parents and
babies.
1. Recovery-oriented system-of-care (ROSC) 2. Non-stigmatizing,
non-labeling language 3. Welcoming environments 4. Trauma-informed
care 5. Resistance and motivational enhancement 6. Strengths-based
and relationship-building
approaches
RECOVERY
WORKING DEFINITION: (SAMHSA, 2011) • “A process of change through
which
individuals improve their health and wellness, live a self-directed
life, and strive to reach their full potential.”
CORE RECOVERY MEASURES: (SAMHSA, 2014) • Health—Overcoming or
managing disease process;
physical/emotional well-being; • Home—Stable and safe place to live
• Purpose—Meaningful daily activities (job, school); and •
Community—relationships and social networks that
provide support, friendship, love and hope.
Recovery is a reality for millions of people;
There are many pathways and styles of recovery;
Recovery is a voluntary process;
Patients thrive in supportive communities;
Recovery gives back what addiction and mental illness took
away.
White & Davidson, 2006; System Transformation. Recovery: The
Bridge to Integration? Behavioral Healthcare, 26(11), 22-25).
Pre-Recovery Identification
Substance Use Disorder Services Continuum-of-Care
RECOVERYHealth Care Provider Responsibilities
a) Pre-Recovery Identification & Engagement: Dependent on a
therapeutic alliance between the practitioner and the patient
• Practitioner: Awareness of a window of opportunity, and
willingness to intervene • Patient: Awareness that the healthcare
provide is helpful and supportive, and
willingness to trust the provider
b) Recovery Initiation & Stabilization: Failure to initiate and
stabilize recovery is due to flaws in the service delivery system,
not failures (non-compliance) of the individual (White, 2008)
c) Sustained Recovery Support Services: Full range of non-clinical
services to reduce or eliminate environmental or personal barriers
to recovery
d) Long-term Recovery Management: • Shifts focus from the service
environment to the client’s natural environment; • Requires
provider commitment to extended post-treatment monitoring &
support.
Employment readiness Legal consultation Wellness checks
Self-management support
Child care Transportation Housing Life skills training
“At the center of the ecological onion rests the individual and the
internal vulnerabilities and assets that the individual brings to
AOD (alcohol/drug) problem-resolution efforts”
White, W.L. (2008). Recovery Management and Recovery-Oriented
Systems of Care: Scientific Rationale and Promising
Practices.
PATIENT-CENTEREDNESS
Stigma: Disgrace associated with a particular circumstance,
quality, or person (www.dictionary.com) Prompted by beliefs that
the individual caused their situation intentionally Terms like
“substance abuser” and “addict” imply that the person willfully
makes bad
choices and has poor moral character
Cognitive Bias: Systematic error in thinking affecting decisions
and judgments (www.verywellmind.com) Providers with negative
attitudes and stereotypical beliefs towards people with
substance use problems demonstrate significant blame and judgment;
and use more punitive, pejorative language
Self-Stigmatization: Internalization of negative stereotypes
(self-stigma) Self-stigma affects the patient’s feelings of
self-worth, self-value, and self-esteem
Words Matter! Stigmatizing words: Bring shame, dishonor, disgrace,
and discrimination Positive words: Directly impact a person’s
treatment success and recovery outcomes
(Burda, 2019)
first treatment session;
Reduce no-shows by reducing the number of patients who do not keep
an appointment;
Increase admissions to treatment;
Increase continuation from the first through the fourth treatment
session.
Relationship-based programs: Beneficial for women in
treatment
Family engagement: Is a fundamental element of treatment (Etheridge
& Hubbard, 2000) Predicts improved retention in treatment
(Liddell, 2004) Can lead to better outcomes (Copello et al.,
2005).
Treatment agencies need to: Find effective ways to meaningfully
engage family members or
significant others (nonresidential children and fathers/father
figures); Support family engagement (Copello, et al., 2009) and
care for the
affected family members. Women, Children, and Family Treatment
(WCFT) NIATx Collaborative Final Report (Madden & Zastowny, et
al., 2011)
(Covington & Cohen, 1984; Miller, Downs & Gondoli,
1989)
Compared to women that have EITHER a post-traumatic stress disorder
(PTSD) OR a substance use disorder (SUD), women with BOTH
suffer:
More co-morbid mental disorders More medical problems More
psychological symptoms More in-patient admissions More
interpersonal problems Lower levels of functioning Poor compliance
with aftercare and motivation for treatment More significant life
problems (Homelessness, HIV, domestic violence) More loss of
custody of children (Covington, 2007; Najavits, Weiss & Shaw,
1997)
Outcomes for women with co-occurring substance and mental disorders
and histories of abuse or trauma are improved when the provider has
adopted a trauma-informed treatment philosophy
Women may use substances to numb the pain of non-mutual,
non-empathetic and violent relationships and to medicate anxiety or
depression
Trauma-informed environments are those that pay attention to
boundaries (intrusion into personal spaces, the right to say no to
hugs), use language that communicates empowerment, and avoid
shaming and punitive approaches
Female trauma survivors may need to receive treatment in women-
only recovery groups.
(Herman, 1997; Covington, 2007)
• If people are not ready to change, we need to:
• Help PREPARE them for CHANGE; and
• Help move them to the NEXT LEVEL OF READINESS.
SIGNS OF PATIENT RESISTANCE include: • Interrupting • Denial •
Ignoring • Arguing
• These are: • Signs that the patient is not feeling HEARD,
RESPECTED, or TAKEN SERIOUSLY; • Clues to check our own behaviors,
plans and expectations.
• Are we rushing ahead to action planning without first checking
the patient’s level of readiness?
• If so, we may be in a “CONFRONTATION-DENIAL TRAP”, inducing the
patient to argue, interrupt, deny the problem, or ignore us even
more.
People who show INSIGHT about: • The RELATIONSHIP between
NEGATIVE CONSEQUENCES and • Their USE of ALCOHOL AND
OTHER DRUGS (AOD)
Will probably: • BE RECEPTIVE to treatment, and • DO WELL in
treatment.
ADAPTED FROM: Ingersoll, K. and Wagner, C. “Motivational
Enhancement Groups for the Virginia SATOE Model,” Va. DMHMRSAS,
1977. © 2002, Va. DMHMRSAS
Problem Recognition, Readiness for Treatment and Motivation
ADAPTED FROM: Ingersoll, K. and Wagner, C. “Motivational
Enhancement Groups for the Virginia SATOE Model,” Va. DMHMRSAS,
1977. © 2002, Va. DMHMRSAS
People who: • Are unable to RECOGNISE their problems, • FAIL TO
DISCLOSE that they have AOD
problems, or • Exhibit DENIAL and MISTRUST---
Will probably be: • HARDER TO ENGAGE in treatment; and
• MORE LIKELY to “DROP OUT”
Problem Recognition, Readiness for Treatment, and Motivation
These persons need to be ASSESSED for TREATMENT READINESS and LEVEL
of MOTIVATION
“MOTIVATIONAL ENHANCEMENT” will help improve the likelihood of
success.
ADAPTED FROM: Ingersoll, K. and Wagner, C. “Motivational
Enhancement Groups for the Virginia SATOE Model,” Va. DMHMRSAS,
1977. © 2002, Va. DMHMRSAS
5 Principles of Motivational Enhancement 1. Communicate RESPECT for
Patients—LISTEN rather than TELL.
2. Help Patients Perceive a DISCREPANCY—between where they ARE, and
where they WANT TO BE
3. Avoid ARGUMENTATION—in order to avoid RESISTANCE. • Resistance
is a PATIENT’S REACTION to what they perceive as a
THREATENING interpersonal interaction. • Resistance is evoked by
DISRESPECT or THREATS to SELF-ESTEEM. • Resistance is minimized by
enhancing SELF-ESTEEM and RESPECTING the patient.
4. Discuss AMBIVALENCE openly—Seek the patient’s opinions about
POSSIBLE SOLUTIONS.
5. Enhance SELF-EFFICACY—the ABILITY to achieve goals. • People
only move towards change when they perceive a CHANCE OF SUCCESS. •
Help the patient BELIEVE she CAN change.
ADAPTED FROM: Ingersoll, K. and Wagner, C. “Motivational
Enhancement Groups for the Virginia SATOE Model,” Virginia
Department of Mental Health, Mental Retardation & Substance
Abuse Services, 1997.
Incorporating Recovery Messages into the Context of General
Health
The more we incorporate advice about substance use with general
health concerns and consequences of continued use, the better our
chances of success.
Patient Factors---40% • Strengths: Talents, past problem-
solving abilities, social supports, beliefs, resources, etc.
Relationship Factors---30% • ALLIANCE between patients and staff; •
Patient perceptions of
EMPATHY, ACCEPTANCE & HOPE
BELIEVES or EXPECTS the intervention will be beneficial
• Whether the counselor can convey the “POSSIBILITY OF
CHANGE”
• HOPE, OPTIMISM and ENCOURAGEMENT improve outcomes
Model/Technique---15% • Least Influential Contributors To
Change:
• What we do as helpers • Our strategies and techniques
• Instead of finding more “effective” models of treatment, we
should elicit, amplify and reinforce the PATIENT and FAMILY
FACTORS.
Mid-Atlantic Addiction Technology Center. Addiction Exchange, Vol.
3, No. 8: Common Factors Research, May 15, 2001
Chart1
Model or Technique: 15%
kf: 052201
All treatment models can be equally effective
Outcomes do not improve when we require patients to “fit” or
“conform” to our favorite model or technique
The biggest engine of change is the patient and family not “us” or
our intervention models
Outcomes improve when we instill hope and accommodate our
patients
Mid-Atlantic Addiction Technology Center. Addiction Exchange, Vol.
3, No. 8: Common Factors Research, May 15, 2001
Katherine Fornili, DNP, MPH, RN, CARN, FIAAN
Assistant Professor
Department of Family & Community Health
655 W. Lombard Street, #545-D
Baltimore, MD 21234
Problem Statement:
OVERARCHING PRINCIPLES OF RECOVERY:
William White’s Recovery Management Model and the Substance Use
Disorders Continuum-of-Care
1. Recovery-Oriented Systems-of-Care: Continued contact is the
responsibility of the primary care provider and other service staff
rather than the patient.
CONCEPTUAL FRAMEWORK: Brofenbrenner’s Ecologic Framework
2. Words Matter! Use non-stigmatizing, non-labeling language
3. Create Welcoming Environments and a Culture of Quality
Improvement: (Network for the Improvement of Addiction Treatment,
NIATx) https://niatx.net
3. Create Welcoming Environments and a Culture of Quality
Improvement: (Network for the Improvement of Addiction Treatment,
NIATx) https://niatx.net
4. Trauma-Informed Care: Avoid Re-traumatization
4. Trauma-Informed Care: Avoid Re-traumatization
5. Resistance and motivational enhancement:DO NOT PUSH people into
changing when they are not ready
5. Resistance and motivational enhancement:DO NOT PUSH people into
changing when they are not ready
Problem Recognition, Readiness for Treatment and Motivation
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A Better Way of Communicating---Focus is not on ABSTINENCEFocus on
helping patients move to the NEXT LEVEL OF READINESS
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